The impact of skeletal muscle on the pharmacokinetics and toxicity of 5-fluorouracil in colorectal cancer

Artificial intelligence-based muscle analysis risk assessment of treatment-related toxicity in metastatic colorectal cancer

IntroductionUp to 60% of adults with metastatic colorectal cancer (mCRC) receiving combination cytotoxic chemotherapy may experience loss of skeletal muscle mass and function. This study explores associations of artificial intelligence (AI)-based skeletal muscle assessment with hematologic toxicity and chemotherapy relative dose intensity (RDI) in adults with mCRC receiving standard combination chemotherapy.MethodsWe conducted a retrospective analysis of adults with mCRC receiving first-line FOLFOX or FOLFIRI over 6 months (≤12 cycles) from 1/2011 to 11/2018. We used a validated AI-based skeletal muscle assessment on baseline (prior to starting chemotherapy) computed tomography scans to determine skeletal muscle index (SMI, cm2/m2), categorizing low SMI using independent sex-specific cut-off values. We sought to evaluate the association between low SMI and the incidence of grade ≥3 (G ≥ 3) cytopenia over 6 months. Secondary endpoints included time to G ≥ 3 cytopenia and RDI.ResultsOverall, 126 adults met inclusion (median age = 61 years [range, 29-85]; 56 [44%] female) with a median BMI of 26.6 kg/m2 (IQR, 24.1-30.5 kg/m2), including 59 (47%) with a low SMI. G ≥ 3 neutropenia incidence was higher in adults with low SMI (31% vs. 15%, p = 0.036). There was no difference for other G ≥ 3 cytopenias (39% vs 24%, p = 0.067) or median time to G ≥ 3 neutropenia (p = 0.053). Patients with a low SMI had a lower 5FU-bolus RDI (p = 0.045).ConclusionAdults with mCRC receiving first-line chemotherapy with low SMI experienced more G ≥ 3 neutropenia and decreased 5-FU bolus RDI.

Association of CVAI, LAP and SMI with risk of haematological toxicity after immunochemotherapy in patients with DLBCL: a retrospective study

Background

The occurrence of adverse events after immunochemotherapy in patients with diffuse large B-cell lymphoma (DLBCL) frequently affects the course of chemotherapy, leading to a further decline in quality of life and survival.

Objectives

The primary objective of this study was to investigate the association between Chinese visceral adiposity index (CVAI), lipid accumulation product (LAP) index and skeletal muscle mass index (SMI) at initial diagnosis and the risk of haematological toxicity following immunochemotherapy in patients with DLBCL.

Design

Retrospective, single-centre study.

Methods

CVAI, LAP and SMI were calculated by combining clinical data of the patients. This study included 213 patients, of whom 117 (55%) patients experienced grades 3-4 haematological toxicity after immunochemotherapy. Participants were divided into four groups (Q1, Q2, Q3, Q4) based on the quartiles of CVAI, LAP and SMI.

Results

In the fully adjusted model, the risk of grades 3-4 haematological toxicity in group with the highest CVAI and LAP was reduced by 75.1% (OR: 0.249, 95% CI: 0.102-0.606, p = 0.002) and by 77.3% (OR: 0.227, 95% CI: 0.095-0.542, p = 0.001) compared to the group with the lowest CVAI and LAP. For SMI, the risk of grades 3-4 haematological toxicities in the group with the highest SMI was reduced by 62.9% compared with the lowest SMI group in the unadjusted model. The multivariable-adjusted restricted cubic spline curves and subgroup interaction analyses further confirmed the robustness of these findings.

Conclusion

The results indicate that DLBCL patients with relatively high CVAI, LAP and SMI at initial diagnosis have a lower risk of severe haematological toxicity following chemotherapy. Therefore, CVAI, LAP and SMI at initial diagnosis are reliable and effective biomarkers for predicting severe haematological toxicity after immunochemotherapy in DLBCL patients.

Trial registration

This is a retrospective study, and no registration on ClinicalTrials.gov.

Sex differences in recovery from postoperative sarcopenia during adjuvant CAPOX therapy for colorectal cancer

BACKGROUND

Women are predisposed to develop intolerance to cancer chemotherapy. Sarcopenia and chemotherapy are mutually related. Women are generally intolerable to chemotherapeutics such as 5-fluorouracil. Although adjuvant oxaliplatin-based chemotherapy, e.g. CAPOX is commonly used to treat colorectal cancer, its effects on patients in terms of sarcopenia and sex remain unknown. We investigated sex disparities in the impacts of CAPOX on body composition in this study.

METHODS

We conducted a prospective study on diagnostic metrics used for sarcopenia in colorectal cancer patients receiving adjuvant CAPOX. Evaluations of the nutritional status by the Mini-Nutritional Assessment (MNA), gait speed, grip strength, skeletal muscle mass, fat mass, and bone mineral content using a body composition analyzer were performed in the first, fourth, and eighth cycles of CAPOX (first, second, and third measurements, respectively).

RESULTS

Among 80 eligible patients, 61 completed four CAPOX cycles. The median differences in MNA, gait, grip strength, muscle mass, fat mass, and bone mineral content between the first and second measurements for men (n = 35) and women (n = 26) were + 10.5% and + 2.9% (p = 0.067), + 4.5% and - 2.6% (p = 0.16), + 1.8% and + 2.8% (p = 0.66), + 2.7% and + 1.3% (p = 0.021), + 4.5% and + 3.5% (p = 0.59), and + 3.3% and + 0.0% (p = 0.006), There were no sex differences in comparisons of the above metrics between the first and third measurements in 34 patients who completed eight CAPOX cycles (19 wen and 15 women).

CONCLUSIONS

Early cycles of adjuvant CAPOX may have a negative impact on the postoperative recovery of several metrics for diagnosing sarcopenia in women.

Nutritional Intervention for the Elderly during Chemotherapy: A Systematic Review

This study aims to review existing literature on the effect of oral nutritional supplements (ONSs) during chemotherapy in older cancer patients. Electronic databases were searched for relevant studies up to March 2024. The risk of bias in the included studies was evaluated using the Cochrane tool. Eligible studies included randomized, prospective, and retrospective studies evaluating the effect of ONSs in elderly (median age > 65 years) cancer patients during chemotherapy. Data regarding chemotherapy adherence, toxicity, overall survival, and nutritional status were extracted. A total of ten studies, involving 1123 patients, were included. A meta-analysis of the results was not conducted due to the scarcity and heterogeneity of results. Some ONSs were associated with reduced incidence of chemotherapy side-effects, particularly oral mucositis, and improved nutritional status. There was limited or no evidence regarding the impact of ONSs on chemotherapy adherence or overall survival. Various types of ONS were investigated, including multimodal intervention with tailored nutritional counseling, whey protein supplements, amino acids supplements (including immune nutrition supplements), and fish oil omega-3-enriched supplements. ONSs showed promise in reducing chemotherapy side-effects and improving nutritional status in older cancer patients, but further studies are needed to explore their efficacy on chemotherapy adherence and overall survival. Future research should consider both chronological age and frailty criteria, account for dietary habits, and use specific nutritional assessment like Bioelectrical Impedance Analysis.

Diagnostic and prognostic value of parameters of erector spinae in patients with uremic sarcopenia

AIM

This study aimed to investigate whether computed tomography (CT)-measured erector spinae parameters (ESPs) have diagnostic, severity assessment, and prognostic predictive value in uremic sarcopenia (US).

MATERIALS AND METHODS

A total of 202 uremic patients were enrolled and divided into two groups: a control group and a sarcopenia group. Sarcopenia was classified into two types: severe and nonsevere. The area, volume, and density of the erector spinae (ES) were measured using chest CT images, and the relevant ESP, including the erector spinae index (ESI), total erector spinae volume (TESV), erector spinae density (ESD), and erector spinae gauge (ESG) were calculated. The occurrence of adverse events was followed-up for 36 months. The diagnostic value and severity of US were determined using the receiver operating characteristic (ROC) curve. Survival curves diagnosed using CT were plotted and compared with the curve drawn using the gold standard. Cox regression analysis was used to identify independent risk factors associated with survival in US.

RESULTS

With an area under the curve (AUC) of 0.840 and 0.739, the combined ESP has diagnostic value and the ability to assess the severity of US. There was no significant difference in the survival curve between the combined ESP for the diagnosis of US and the gold standard (P > 0.05). ESI is a standalone predictor of survival in patients with US.

CONCLUSION

ESP measured by CT has diagnostic values for US and its severity, as well as being a predictive value for the prognosis of US.

Nutritional Status Indicators Predict Tolerability to Adjuvant Chemotherapy in Patients with Stage II/III Rectal Cancer Undergoing Neoadjuvant Chemoradiotherapy

INTRODUCTION

Adjuvant chemotherapy (AC) after radical surgery following preoperative chemoradiotherapy (CRT) for locally advanced rectal cancer (LARC) is now the standard of care. The identification of risk factors for the discontinuation of AC is important for further improvements in survival. We herein examined the prognostic impact of chemotherapy compliance and its relationship with the prognostic nutritional index (PNI) before surgery.

METHODS

A total of 335 stage II-III LARC patients who underwent preoperative CRT between 2003 and 2022 at the University of Tokyo Hospital were retrospectively reviewed. We excluded patients with recurrence during AC and those who had not received AC. The relationship between AC and long-term outcomes and that between PNI values and the duration of AC were examined.

RESULTS

Thirty-one patients discontinued AC and 62 continued AC. Recurrence-free survival (RFS) was significantly shorter in patients who discontinued AC (p = 0.0056). The discontinuation of AC was identified as an independent risk factor for RFS (hazard ratio [HR]: 2.24, p = 0.0233). Twenty-one patients were classified as having low PNI (less than 40), which correlated with an older age, low body mass index, and incomplete AC. Low PNI was an independent risk factor for a shorter duration of AC (HR: 2.53, p = 0.0123).

CONCLUSION

The discontinuation of AC was related to poor RFS in patients with LARC undergoing preoperative CRT. Furthermore, a low PNI value was identified as a risk factor for a shorter duration of AC.

Influence of malnutrition according to the glim criteria on the chemotherapy toxicities in patients with advanced lung cancer

BACKGROUND

Cancer-associated malnutrition is highly prevalent in advanced lung cancer, and 50% of global cancer-related deaths are attributed to cancer-associated malnutrition. Platinum-containing chemotherapy is the standard treatment for advanced lung cancer. Unfortunately, it can cause exacerbated toxicities, which can also have a negative impact on patient's prognosis and quality of life. The Global Leadership Initiative on Malnutrition (GLIM) criteria have been proposed as the world's first accepted diagnostic criteria for malnutrition. However, the effectiveness of GLIM criteria in predicting chemotherapy toxicities in patients with advanced lung cancer is unclear. The aim of this study was to apply the GLIM criteria to assess the prevalence of pre-treatment diagnosis of malnutrition in patients with advanced non-small cell lung cancer (NSCLC) and to determine the impact of nutritional status on patient's chemotherapy toxicity.

METHODS

We conducted a study of hospitalized patients with pathologically and clinically diagnosed advanced NSCLC who presented to our hospital from May 2021 to January 2022. Initially, the Nutritional Risk Screening-2002 (NRS-2002) was used for nutritional risk screening, and nutritional status was assessed using the Scored Patient-Generated Subjective Global Assessment (PG-SGA) and GLIM criteria. Chemotherapy toxicity was assessed and graded according to CTCAE5.0, and chemotherapy efficacy was assessed according to RECIST1.1. Kappa test was used to analyze the agreement between PG-SGA and GLIM criteria. Univariate and multivariate logistic regression analyses were used to determine the relationship between malnutrition and chemotherapy toxicity.

RESULTS

A total of 215 patients with advanced NSCLC were evaluated for nutritional status. Most of the patients had normal BMI (61.86%) before the start of treatment, 40% were well-nourished as assessed by the PG-SGA tool, and 51.17% were well-nourished as assessed by GLIM criteria. Consistency analysis showed moderate agreement (Kappa = 0.463, P < 0.001) and their correlation was also moderate (Spearman, rs = 0.475, P < 0.001). The objective response rate (ORR) (P = 0.040) and disease control rate (DCR) (P < 0.001) were significantly lower in malnourished patients diagnosed according to GLIM criteria than in well-nourished patients. Multivariate analysis showed that malnutrition (OR = 1.531,95%CI 0.757-3.009; OR = 6.623,95%CI 1.390-31.567, P = 0.046) diagnosed by GLIM criteria was an independent predictor of chemotherapy toxicity. Conclusions Malnutrition diagnosed by GLIM criteria better predicts toxicity during chemotherapy, determines the degree of clinical benefit of chemotherapy, and may affect patient prognosis.

Effect of Obesity on the Pharmacokinetics and Pharmacodynamics of Anticancer Agents

An objective of the Precision Medicine Initiative, launched in 2015 by the US Food and Drug Administration and National Institutes of Health, is to optimize and individualize dosing of drugs, especially anticancer agents, with high pharmacokinetic and pharmacodynamic variability. The American Society of Clinical Oncology recently reported that 40% of obese patients receive insufficient chemotherapy doses and exposures, which may lead to reduced efficacy, and recommended pharmacokinetic studies to guide appropriate dosing in these patients. These issues will only increase in importance as the incidence of obesity in the population increases. This publication reviews the effects of obesity on (1) tumor biology, development of cancer, and antitumor response; (2) pharmacokinetics and pharmacodynamics of small-molecule anticancer drugs; and (3) pharmacokinetics and pharmacodynamics of complex anticancer drugs, such as carrier-mediated agents and biologics. These topics are not only important from a scientific research perspective but also from a drug development and regulator perspective. Thus, it is important to evaluate the effects of obesity on the pharmacokinetics and pharmacodynamics of anticancer agents in all categories of body habitus and especially in patients who are obese and morbidly obese. As the effects of obesity on the pharmacokinetics and pharmacodynamics of anticancer agents may be highly variable across drug types, the optimal dosing metric and algorithm for difference classes of drugs may be widely different. Thus, studies are needed to evaluate current and novel metrics and methods for measuring body habitus as related to optimizing the dose and reducing pharmacokinetic and pharmacodynamic variability of anticancer agents in patients who are obese and morbidly obese.

Sarcopenia is an Independent Prognostic Factor in Patients With Pancreatic Cancer - a Meta-analysis

RATIONALE AND OBJECTIVES

Sarcopenia is defined as skeletal muscle loss and can be assessed by cross-sectional imaging. Our aim was to establish the effect of sarcopenia on relevant outcomes in patients with pancreatic ductal adenocarcinoma (PDAC) in curative and palliative settings based on a large patient sample.

MATERIALS AND METHODS

MEDLINE library, EMBASE and SCOPUS databases were screened for the associations between sarcopenia and mortality in patients with PDAC up to March 2022. The primary endpoint of the systematic review was the hazard ratio of Sarcopenia on survival. 22 studies were included into the present analysis.

RESULTS

The included 22 studies comprised 3958 patients. The prevalence of sarcopenia was 38.7%. Sarcopenia was associated with a higher prevalence in the palliative setting (OR 53.23, CI 39.00-67.45, p<0.001) compared to the curative setting (OR 36.73, CI 27.81-45.65, p<0.001). Sarcopenia was associated with worse OS in the univariable (HR 1.79, CI 1.41-2.28, p<0.001) and multivariable analysis (HR 1.62, CI 1.27-2.07, p<0.001) in the curative setting. For the palliative setting the pooled hazards ratio showed that sarcopenia was associated with overall survival (HR 1.56, CI 1.21-2.02, p<0.001) as well as in multivariable analysis (HR 1.77, CI 1.39-2.26, p<0.001). Sarcopenia was not associated with a higher rate of post-operative complications in univariable analysis (OR 1.10, CI 0.70-1.72, p = 0.69).

CONCLUSION

Sarcopenia occurs in 38.7% of patients with pancreatic cancer, significantly more in the palliative setting. Sarcopenia is associated with overall survival in both settings. The assessment of sarcopenia is therefore relevant for personalized oncology. Sarcopenia is not associated with postoperative complications.

Pharmacokinetics of cancer therapeutics and energy balance: the role of diet intake, energy expenditure, and body composition

Energy balance accounts for an individual's energy intake, expenditure, and storage. Each aspect of energy balance has implications for the pharmacokinetics of cancer treatments and may impact an individual's drug exposure and subsequently its tolerance and efficacy. However, the integrated effects of diet, physical activity, and body composition on drug absorption, metabolism, distribution, and excretion are not yet fully understood. This review examines the existing literature on energy balance, specifically the role of dietary intake and nutritional status, physical activity and energy expenditure, and body composition on the pharmacokinetics of cancer therapeutics. As energy balance and pharmacokinetic factors can be influenced by age-related states of metabolism and comorbidities, this review also explores the age-related impact of body composition and physiologic changes on pharmacokinetics among pediatric and older adult populations with cancer.

Pre-Therapeutic Sarcopenia among Cancer Patients: An Up-to-Date Meta-Analysis of Prevalence and Predictive Value during Cancer Treatment

This study will address the prevalence of pre-therapeutic sarcopenia (PS) and its clinical impact during cancer treatment among adult cancer patients ≥ 18 years of age. A meta-analysis (MA) with random-effect models was performed via a MEDLINE systematic review, according to the PRISMA statement, focusing on articles published before February 2022 that reported observational studies and clinical trials on the prevalence of PS and the following outcomes: overall survival (OS), progression-free survival (PFS), post-operative complications (POC), toxicities (TOX), and nosocomial infections (NI). A total of 65,936 patients (mean age: 45.7-85 y) with various cancer sites and extensions and various treatment modes were included. Mainly defined by CT scan-based loss of muscle mass only, the pooled prevalence of PS was 38.0%. The pooled relative risks were 1.97, 1.76, 2.70, 1.47, and 1.76 for OS, PFS, POC, TOX, and NI, respectively (moderate-to-high heterogeneity, I²: 58-85%). Consensus-based algorithm definitions of sarcopenia, integrating low muscle mass and low levels of muscular strength and/or physical performance, lowered the prevalence (22%) and heterogeneity (I² < 50%). They also increased the predictive values with RRs ranging from 2.31 (OS) to 3.52 (POC). PS among cancer patients is prevalent and strongly associated with poor outcomes during cancer treatment, especially when considering a consensus-based algorithm approach.

Low pretherapy skeletal muscle mass index is associated with an increased risk of febrile neutropenia in patients with esophageal cancer receiving docetaxel + cisplatin + 5-fluorouracil (DCF) therapy

PURPOSE

Docetaxel + cisplatin + 5-fluorouracil (DCF) therapy, a frequently prescribed regimen for esophageal cancer, is associated with a high risk of febrile neutropenia (FN). This study investigated whether a low skeletal muscle mass index (SMI) is an independent risk factor for FN.

METHODS

This retrospective, observational study investigated the SMI of patients with esophageal cancer who received DCF therapy between March 2018 and July 2020. Based on the Asian sarcopenia criteria, patients were divided into two groups: high and low SMI (SMI of < 7.0 and 5.7 kg/m2 for males and females, respectively). The incidence of FN was then compared between the two groups.

RESULTS

Thirty-nine patients (20 and 19 in the high- and low-SMI groups, respectively) were included in this study. The incidence of FN was significantly higher in the low-SMI group (63.2% vs. 20.0%, P = 0.006). Univariable and multivariable logistic regression analyses revealed that a low SMI was an independent risk factor for FN (odds ratio, 7.178; 95% confidence interval, 1.272-40.507; P = 0.026). In addition, the frequency of dose reduction in DCF therapy was significantly higher in the low-SMI group (68.4% vs. 35.0%, P = 0.037).

CONCLUSION

Low SMI is an independent risk factor for FN in patients with esophageal cancer receiving DCF therapy.

Influence of the skeletal muscle index on pharmacokinetics and toxicity of fluorouracil

BACKGROUND

The body composition of patients has been associated with tolerability and effectiveness of anticancer therapy. This study aimed to assess the influence of the skeletal muscle index (SMI) on the pharmacokinetics and toxicity of fluorouracil.

METHODS

Patients treated in an oncological practice with fluorouracil-based chemotherapy and undergoing therapeutic drug monitoring were retrospectively investigated. Computed tomography images were analyzed to measure abdominal skeletal muscle areas in Hounsfield units for the psoas major muscle, back and total skeletal muscle to determine the SMI. For the latter, an automated segmentation method was used additionally. SMI measures were tested as covariates on fluorouracil clearance in a population pharmacokinetic model. Furthermore, regression analyses were performed to analyze the influence of SMI measures on the probability of clinically relevant adverse events (CTCAE grades ≥ 2).

RESULTS

Fluorouracil plasma concentrations of 111 patients were available. Covariate analyses showed significant improvements of the model fit by all SMI measures. However, interindividual variability of fluorouracil clearance was only slightly reduced, whereas the SMI of the back muscle showed the largest reduction (-1.1 percentage points). Lower SMI values of the back muscle increased the probability for polyneuropathy and lower SMI of the psoas increased the probability for fatigue.

CONCLUSIONS

Our results suggest that pharmacokinetics and toxicity of fluorouracil may be associated with specific SMI measures which deserve further investigation.

Sarcopenia detected with bioelectrical impedance versus CT scan and chemotherapy tolerance in patients with early breast cancer

BACKGROUND

Early breast cancer (EBC) is a potentially curable disease. Some patients with EBC require chemotherapy, exposing patients to undesirable side effects. Loss of muscle mass, or sarcopenia, has been associated with worse outcomes in patients with EBC and worse treatment-related toxicity in patients with advanced breast cancer. CT scans can identify sarcopenia; however, most patients with EBC do not require routine CT scans. Bioelectrical impedance spectrometry (BIS) is another method to detect sarcopenia and can be performed quickly in the office without radiation exposure. We sought to investigate whether sarcopenia measurements by CT scan versus BIS correlated with each other and whether sarcopenia identified by each method is associated with chemotherapy toxicity and adherence in patients with EBC.

METHODS

This is a retrospective study; eligible patients received chemotherapy treatment for EBC and had undergone BIS. A subset of patients had also had a CT abdomen with a Lumbar L3 level. Measures of sarcopenia were obtained from the BIS and CT data. In addition, patient characteristics, treatment, and toxicity-related outcomes were obtained from medical records. Multivariate logistic regression models were used to associate sarcopenia status with toxicity endpoints, adjusted for other patient characteristics.

RESULTS

There was a moderate correlation between sarcopenia detected by CT scan and BIS (r = 0.64 p < 0.0001). Patients with sarcopenia detected by BIS had more chemotherapy toxicity (OR = 2.56; CI 1.72-3.84), dose reductions or dose delays (OR = 1.58; CI 1.06-2.38), and hospitalizations (OR = 2.38; CI 1.33-4.16) due to side effects than patients without sarcopenia.

CONCLUSION

The presence of sarcopenia in patients with EBC is associated with worse chemotherapy tolerance. BIS represents a high-value alternative to CT scans for sarcopenia assessment.

Chemotherapy-induced cachexia and model-informed dosing to preserve lean mass in cancer treatment

Although chemotherapy is a standard treatment for cancer, it comes with significant side effects. In particular, certain agents can induce severe muscle loss, known as cachexia, worsening patient quality of life and treatment outcomes. 5-fluorouracil, an anti-cancer agent used to treat several cancers, has been shown to cause muscle loss. Experimental data indicates a non-linear dose-dependence for muscle loss in mice treated with daily or week-day schedules. We present a mathematical model of chemotherapy-induced muscle wasting that captures this non-linear dose-dependence. Area-under-the-curve metrics are proposed to quantify the treatment’s effects on lean mass and tumour control. Model simulations are used to explore alternate dosing schedules, aging effects, and morphine use in chemotherapy treatment with the aim of better protecting lean mass while actively targeting the tumour, ultimately leading to improved personalization of treatment planning and improved patient quality of life.

In this paper we present a novel mathematical model for muscle loss due to cancer chemotherapy treatment. Loss of muscle mass relates to increased drug toxicity and side-effects, and to decreased patient quality of life and survival rates. With our model, we examine the therapeutic efficacy of various dosing schedules with the aim of controlling a growing tumour while also preserving lean mass. Preservation of body composition, in addition to consideration of inflammation and immune interactions, the gut microbiome, and other systemic health measures, may lead to improved patient-specific treatment plans that improve patient quality of life.

Current status and future outlooks on therapeutic drug monitoring of fluorouracil

INTRODUCTION

: Therapeutic drug monitoring (TDM) of the anticancer drug fluorouracil (5FU) as a method to support dose adjustments has been researched and discussed extensively. Despite manifold evidence of the advantages of 5FU-TDM, traditional body surface area (BSA)-guided dosing is still widely applied.

AREAS COVERED

: This review covers the latest evidence on 5FU-TDM based on a literature search in PubMed between June and September 2021. It particularly highlights new approaches of implementing 5FU-TDM into precision medicine by combining TDM with pharmacogenetic testing and/or pharmacometric models. This review further discusses remaining obstacles in order to incorporate 5FU-TDM into clinical routine.

EXPERT OPINION

: New data on 5FU-TDM further strengthen the advantages compared to BSA-guided dosing as it is able to reduce pharmacokinetic variability and thereby improve treatment efficacy and safety. Interprofessional collaboration has the potential to overcome the remaining barriers for its implementation. Pre-emptive pharmacogenetic testing followed by 5FU-TDM can further improve 5FU exposure in a substantial proportion of patients. Developing a model framework integrating pharmacokinetics and pharmacodynamics of 5FU will be crucial to fully advance into the precision medicine era. Model applications can potentially support clinicians in dose finding before starting chemotherapy. Additionally, TDM provides further assistance in continuously improving model predictions.

Low skeletal muscle mass is a predictor of treatment related toxicity in oncologic patients. A meta-analysis

BACKGROUND & AIMS

The purpose of this meta-analysis was to summarize the published data regarding associations between occurrence of severe treatment related toxicity and low skeletal muscle mass (LSMM) in oncologic patients and to perform a meta-analysis based on a large sample.

METHODS

MEDLINE, Cochrane, and SCOPUS databases were screened for associations between LSMM and treatment related toxicity in oncologic patients up to June 2021. Overall, 48 studies met the inclusion criteria. The following data were extracted: authors, year of publication, study design, number of patients, influence of LSMM on treatment toxicity (odds ratios and confidence intervals). The methodological quality of the involved studies was checked according to the QUADAS instrument. The meta-analysis was undertaken by using RevMan 5.4 software. DerSimonian and Laird random-effects models with inverse-variance weights were used to account for the heterogeneity between the studies.

RESULTS

The included 48 studies comprised 4803 patients with different malignant diseases. LSMM occurred in 1966 patients (40.9%). LSMM was associated with therapy toxicity (simple logistic regression) with an odds ratio OR = 2.19, CI95%= (1.78-2.68). LSMM was associated with DLT in patients underwent curative treatment (16 studies, 2381 patients) with OR = 2.48, CI95%= (1.77-3.48). LSMM predicted DLT in patients underwent palliative chemotherapy (30 studies, 2337 patients)with OR = 2.06, CI95%= (1.56-2.74). In the subgroups received different palliative therapies, relationships between LSMM and DLT were as follows: conventional chemotherapies (7 studies, 600 patients) OR = 2.14, CI95%= (1.38-3.31); different kinases inhibitors (13 studies, 906 patients) OR = 3.08, CI95%= (1.87-5.09); checkpoint inhibitors (7 studies, 557 patients) OR = 1.30, CI95%= (0.79-2.11).

CONCLUSIONS

LSMM is an essential factor of treatment toxicity in oncologic patients. Association between LSMM and DLT is strongest in patients received therapy with kinases inhibitors. The influence of LSMM on DLT is lowest in patients underwent treatment with checkpoint inhibitors. The presence of LSMM should be included into radiological reports and provided to oncologists to optimize chemotherapy. LSMM should be included into dose calculation for chemotherapy.

The influence process of sarcopenia on female cancer: A systematic review and meta-analysis

BACKGROUND

Sarcopenia is one of the early pathological manifestations of cancer cachexia. This change in quality and function has a general and special impact on the prognosis of many types of tumors. However, there are few studies to evaluate the overall impact of sarcopenia on the prognosis of gynecological tumors in sufficient follow-up period.

METHODS

This study systematically searched PubMed, EMBASE, web of science, and MEDLINE databases for related studies and related references since April 15, 2021. The 1-year, 5-year overall survival (OS), progression-free survival (PFS), hazard ratio (HR), and 95% confidence interval (CI) were analyzed by Stata 14.0.(CRD 42021236036).

RESULTS

A total of 23 observational studies involving 3495 female patients were included in the analysis, with an average prevalence of 46.9% (38.5%-55.3%). Meta-analysis showed that the 1-year OS (RR: 1.60, 95% CI = [1.04, 2.46]) of patients with sarcopenia was significantly lower than that of patients without sarcopenia, and then this effect gradually decreased. The results showed that sarcopenia was an independent predictor of OS (HR: 1.78, 95% CI = [1.38, 2.30]) and PFS (HR: 1.32, 95% CI = [1.02, 1.70]) in gynecological cancer patients. Subgroup analysis showed that sarcopenia was significant in Asian population (HR: 1.93, 95% CI = [1.18, 3.17]) and cervical cancer patients (HR: 5.07, 95% CI = [2.82, 9.56]).

CONCLUSION

The survival and recurrence outcome of patients with sarcopenia independently related to surgery, and its impact is very obvious in the short term. In addition, Asian participants with sarcopenia face a greater risk of death than Western participants.

Body Composition and Dose-limiting Toxicity in Colorectal Cancer Chemotherapy Treatment; a Systematic Review of the Literature. Could Muscle Mass be the New Body Surface Area in Chemotherapy Dosing?

Chemotherapy dosing is traditionally based on body surface area calculations; however, these calculations ignore separate tissue compartments, such as the lean body mass (LBM), which is considered a big pool of drug distribution. In our era, colorectal cancer patients undergo a plethora of computed tomography scans as part of their diagnosis, staging and monitoring, which could easily be used for body composition analysis and LBM calculation, allowing for personalised chemotherapy dosing. This systematic review aims to evaluate the effect of muscle mass on dose-limiting toxicity (DLT), among different chemotherapy regimens used in colorectal cancer patients. This review was carried out according to the PRISMA guidelines. MEDLINE and EMBASE databases were searched from 1946 to August 2019. The primary search terms were 'sarcopenia', 'myopenia', 'chemotherapy toxicity', 'chemotherapy dosing', 'dose limiting toxicity', 'colorectal cancer', 'primary colorectal cancer' and 'metastatic colorectal cancer'. Outcomes of interest were - DLT and chemotoxicity related to body composition, and chemotherapy dosing on LBM. In total, 363 studies were identified, with 10 studies fulfilling the selection criteria. Seven studies were retrospective and three were prospective. Most studies used the same body composition analysis software but the chemotherapy regimens used varied. Due to marked study heterogeneity, quantitative data synthesis was not possible. Two studies described a toxicity cut-off value for 5-fluorouracil and one for oxaliplatin based on LBM. The rest of the studies showed an association between different body composition metrics and DLTs. Prospective studies are required with a larger colorectal cancer cohort, longitudinal monitoring of body composition changes during treatment, similar body composition analysis techniques, agreed cut-off values and standardised chemotherapy regimens. Incorporation of body composition analysis in the clinical setting will allow early identification of sarcopenic patients, personalised dosing based on their LBM and early optimisation of these patients undergoing chemotherapy.

Worse capecitabine treatment outcome in patients with a low skeletal muscle mass is not explained by altered pharmacokinetics

Background

A low skeletal muscle mass (SMM) has been associated with increased toxicity and shorter survival in cancer patients treated with capecitabine, an oral prodrug of 5‐fluorouracil (5‐FU). Capecitabine and its metabolites are highly water‐soluble and, therefore, more likely to distribute to lean tissues. The pharmacokinetics (PK) in patients with a low SMM could be changed, for example, by reaching higher maximum plasma concentrations. In this study, we aimed to examine whether the association between a low SMM and increased toxicity and shorter survival could be explained by altered PK of capecitabine and its metabolites.

Methods

Previously, a population PK model of capecitabine and metabolites in patients with solid tumors was developed. In our analysis, we included patients from this previous analysis for which evaluable abdominal computed tomography (CT)‐scans were available. SMM was measured on CT‐scans, by single slice evaluation at the third lumbar vertebra, using the Slice‐o‐Matic software. The previously developed population PK model was extended with SMM as a covariate, to assess the association between SMM and capecitabine and metabolite PK.

Results

PK and SMM data were available from 151 cancer patients with solid tumors. From the included patients, 55% had a low SMM. No relevant relationships were found between SMM and the PK parameters of capecitabine and, the active and toxic metabolite, 5‐FU. SMM only correlated with the PK of the, most hydrophilic, but inactive and non‐toxic, metabolite α‐fluoro‐β‐alanine (FBAL). Patients with a low SMM had a smaller apparent volume of distribution and lower apparent clearance of FBAL.

Conclusions

No alterations in PK of capecitabine and the active and toxic metabolite 5‐FU were observed in patients with a low SMM. Therefore, the previously identified increased toxicity and shorter survival in patients with a low SMM, could not be explained by changes in pharmacokinetic characteristics of capecitabine and metabolites.

The impact of age on antiretroviral drug pharmacokinetics in the treatment of adults living with HIV

INTRODUCTION

People living with HIV (PLWH) are aging and will receive life-long treatment: despite substantial improvement in drug efficacy and tolerability, side effects still occur and they can blunt antiretroviral treatment effectiveness. Since age may affect drug exposure and may be associated with side-effects we aimed at reviewing available data on the effect of age on antiretrovirals' pharmacokinetics in adult patients.

AREAS COVERED

We searched public databases and major conference proceedings for data on age and pharmacokinetics/pharmacodynamics in PLWH. We limited our review to currently used drugs and focused on population pharmacokinetics and physiologically-based pharmacokinetic modeling studies.

EXPERT OPINION

Available evidence of a potential detrimental effect in elderly PLWH is limited by study design and small sample sizes. Careful consideration of undoubtful benefits and potential harms is advised when prescribing ARVs to geriatric patients and the knowledge of pharmacokinetics changes need to be included in the process. With the 'greying' of the pandemic we need studies with a specific focus on geriatric patients living with HIV that will consider specific phenotypes and associated changes (including sarcopenia).

Individualized Dosing of Fluoropyrimidine-Based Chemotherapy to Prevent Severe Fluoropyrimidine-Related Toxicity: What Are the Options?

Fluoropyrimidines are widely used in the treatment of several types of solid tumors. Although most often well tolerated, severe toxicity is encountered in ~ 20-30% of the patients. Individualized dosing for these patients can reduce the incidence of severe fluoropyrimidine-related toxicity. However, no consensus has been achieved on which dosing strategy is preferred. The most established strategy for individualized dosing of fluoropyrimidines is upfront genotyping of the DPYD gene. Prospective research has shown that DPYD-guided dose-individualization significantly reduces the incidence of severe toxicity and can be easily applied in routine daily practice. Furthermore, the measurement of the dihydropyrimidine dehydrogenase (DPD) enzyme activity has shown to accurately detect patients with a DPD deficiency. Yet, because this assay is time-consuming and expensive, it is not widely implemented in routine clinical care. Other methods include the measurement of pretreatment endogenous serum uracil concentrations, the uracil/dihydrouracil-ratio, and the 5-fluorouracil (5-FU) degradation rate. These methods have shown mixed results. Next to these methods to detect DPD deficiency, pharmacokinetically guided follow-up of 5-FU could potentially be used as an addition to dosing strategies to further improve the safety of fluoropyrimidines. Furthermore, baseline characteristics, such as sex, age, body composition, and renal function have shown to have a relationship with the development of severe toxicity. Therefore, these baseline characteristics should be considered as a dose-individualization strategy. We present an overview of the current dose-individualization strategies and provide perspectives for a future multiparametric approach.

Pathophysiological mechanisms explaining poor clinical outcome of older cancer patients with low skeletal muscle mass

Low skeletal muscle mass is highly prevalent in older cancer patients and affects 5% to 89% depending on the type and stage of cancer. Low skeletal muscle mass is associated with poor clinical outcomes such as post-operative complications, chemotherapy toxicity and mortality in older cancer patients. Little is known about the mediating pathophysiological mechanisms. In this review, we summarize proposed pathophysiological mechanisms underlying the association between low skeletal muscle mass and poor clinical outcomes in older cancer patients including a) systemic inflammation; b) insulin-dependent glucose handling; c) mitochondrial function; d) protein status and; e) pharmacokinetics of anticancer drugs. The mechanisms of altered myokine balance negatively affecting the innate and adaptive immune system, and altered pharmacokinetics of anticancer drugs leading to a relative overdosage of anticancer drugs are best-substantiated. The effects of glucose intolerance and circulating mitochondrial DNA as a consequence of low skeletal muscle mass are topics of interest for future research. Restoring myokine balance through physical exercise, exercise mimetics, neuro-muscular activation and adapting anticancer drug dosing on skeletal muscle mass could be targeted approaches to improve clinical outcomes in older cancer patients with low skeletal muscle mass.

The Acute Effects of 5 Fluorouracil on Skeletal Muscle Resident and Infiltrating Immune Cells in Mice

5 fluorouracil (5FU) has been a first-choice chemotherapy drug for several cancer types (e.g., colon, breast, head, and neck); however, its efficacy is diminished by patient acquired resistance and pervasive side effects. Leukopenia is a hallmark of 5FU; however, the impact of 5FU-induced leukopenia on healthy tissue is only becoming unearthed. Recently, skeletal muscle has been shown to be impacted by 5FU in clinical and preclinical settings and weakness and fatigue remain among the most consistent complaints in cancer patients undergoing chemotherapy. Monocytes, or more specifically macrophages, are the predominate immune cell in skeletal muscle which regulate turnover and homeostasis through removal of damaged or old materials as well as coordinate skeletal muscle repair and remodeling. Whether 5FU-induced leukopenia extends beyond circulation to impact resident and infiltrating skeletal muscle immune cells has not been examined. The purpose of the study was to examine the acute effects of 5FU on resident and infiltrating skeletal muscle monocytes and inflammatory mediators. Male C57BL/6 mice were given a physiologically translatable dose (35 mg/kg) of 5FU, or PBS, i.p. once daily for 5 days to recapitulate 1 dosing cycle. Our results demonstrate that 5FU reduced circulating leukocytes, erythrocytes, and thrombocytes while inducing significant body weight loss (>5%). Flow cytometry analysis of the skeletal muscle indicated a reduction in total CD45+ immune cells with a corresponding decrease in total CD45+CD11b+ monocytes. There was a strong relationship between circulating leukocytes and skeletal muscle CD45+ immune cells. Skeletal muscle Ly6cHigh activated monocytes and M1-like macrophages were reduced with 5FU treatment while total M2-like CD206+CD11c- macrophages were unchanged. Interestingly, 5FU reduced bone marrow CD45+ immune cells and CD45+CD11b+ monocytes. Our results demonstrate that 5FU induced body weight loss and decreased skeletal muscle CD45+ immune cells in association with a reduction in infiltrating Ly6cHigh monocytes. Interestingly, the loss of skeletal muscle immune cells occurred with bone marrow cell cycle arrest. Together our results highlight that skeletal muscle is sensitive to 5FU's off-target effects which disrupts both circulating and skeletal muscle immune cells.

Alterations in drug disposition in older adults: a focus on geriatric syndromes

INTRODUCTION

Age-associated physiological changes can alter the disposition of drugs, however, pathophysiological changes associated with geriatric syndromes in older adults may lead to even greater heterogeneity in pharmacokinetics. Geriatric syndromes are common health problems in older adults which have multifactorial causes and do not fit into distinct organ-based disease categories. With older adults being the greatest users of medications, understanding both age- and geriatric syndrome-related changes is important clinically to ensure safe and effective medication use.

AREAS COVERED

This review provides an overview of current evidence regarding pharmacokinetic alterations that occur with aging and in common geriatric syndromes, including frailty, sarcopenia, dementia, polypharmacy and enteral feeding. The evidence is presented according to the four primary pharmacokinetic processes (Absorption, Distribution, Metabolism and Excretion).

EXPERT OPINION

There is some evidence to inform our understanding of the impact of chronological aging and various geriatric syndromes on drug disposition. However, many areas require more research, including drug induced inhibition and induction of cytochrome P450 enzymes and the clinical utility of emerging methods for estimating renal function. There is a need to develop tools to predict alterations in drug disposition in subgroups of older adults, particularly where the currently available clinical information is sparse.

Cancer cachexia and treatment toxicity

PURPOSE OF REVIEW

Cancer cachexia is a metabolic disturbance resulting in a loss of skeletal muscle mass that is generally not reversed through traditional nutritional interventions. We review on both the impact of nutritional status on cancer treatment side effects, as well as cancer- specific outcomes.

RECENT FINDINGS

Cancer-specific cachexia and sarcopenia are associated with increased treatment-associated toxicity, and overall worse cancer-specific outcomes across all cancer types in surgical, chemotherapeutic, and radiotherapeutic populations. Despite the fact that cancer cachexia is generally thought to be irreversible, there is some evidence that nutritional intervention can be helpful.

SUMMARY

Nutritional status is an important factor to consider in determining cancer therapy. Patients with poor nutritional status should be identified prior to the initiation of therapy and be monitored judiciously.

Is cachexia associated with chemotherapy toxicities in gastrointestinal cancer patients? A prospective study

BACKGROUND

Chemotherapy is an effective treatment with good clinical response in patients with cancer. However, it can cause exacerbated toxicities in patients and consequently change the course of treatment. Some factors may interfere with this toxicity such as body composition, especially in gastrointestinal cancer. The aim of this study was to evaluate the effects of body composition, nutritional status, and functional capacity scale in predicting the occurrence of toxicities in gastrointestinal cancer patients during chemotherapy treatment.

METHODS

This is a prospective study with gastrointestinal cancer patients at the beginning of chemotherapy treatment. Sarcopenia and muscle attenuation were assessed using the skeletal muscle index from computerized tomography by measuring cross-sectional areas of the L3 tissue (cm² /m² ). Cachexia was graded according to involuntary weight loss associated with sarcopenia. Nutritional status was assessed by using anthropometric evaluation and Patient-Generated Subjective Global Assessment. Functional capacity was evaluated by handgrip strength and Eastern Cooperative Oncology Group (ECOG) Performance Status scale. Haematological gastrointestinal and dose-limiting toxicities (DLTs) were defined according to National Cancer Institute Common Toxicity Criteria. The associations among sarcopenia, cachexia, nutritional status, and functional capacity with DLT were assessed by univariate and multivariate Cox regression model.

RESULTS

A total of 60 patients were evaluated (55% male, 60.9 ± 14.0 years) and followed up for a mean of 55 days. Most patients had normal weight (44.2%) and good ECOG Performance Status (≤1) at baseline (78%). During the chemotherapy period, the most prevalent toxicities were diarrhoea, nausea, and anorexia, but the presence of DLT was similar between cycles (P > 0.05). Cachexia was associated with a higher toxicity manifested by diarrhoea (P = 0.02), nausea (P = 0.02), and anorexia (P < 0.01 and P = 0.03 at Cycles 1 and 2, respectively). Sarcopenic and cachetic individuals experienced more toxicities and DLT during chemotherapy. The only factors associated with DLT in the multivariate Cox regression analyses including the presence of metastasis and the chemotherapy protocol were cachexia and the ECOG scale (P < 0.001 for both).

CONCLUSIONS

Cachexia and ECOG score may identify patients with an increased risk for developing severe toxicity events during chemotherapy treatment for gastrointestinal cancer.

Clinical implications of low skeletal muscle mass in early-stage breast and colorectal cancer

Although obesity has now been widely accepted to be an important risk factor for cancer survival, the associations between BMI and cancer mortality have not been consistently linear. Although morbid obesity has clearly been associated with worse survival, some studies have suggested a U-shaped association with no adverse association with overweight or lower levels of obesity. This 'obesity paradox' may be due to the fact that BMI likely incompletely captures key measures of body composition, including distribution of skeletal muscle and adipose tissue. Fat and lean body mass can be measured using clinically acquired computed tomography scans. Many of the earlier studies focused on patients with metastatic cancer. However, skeletal muscle loss in the metastatic setting may reflect end-stage disease processes. Therefore, this article focuses on the clinical implication of low skeletal muscle mass in early-stage non-metastatic breast and colorectal cancer where measures of body composition have been shown to be strong predictors of disease-free survival and overall survival and also chemotherapy toxicity and operative risk.

Interactions of lean soft-tissue and chemotherapy toxicities in patients receiving anti-cancer treatments

Use of cross-sectional imaging to identify whole-body lean soft-tissue mass has recently emerged as an attractive prognostic factor for chemotherapy toxicities. Beyond that, there is increasing interest in use of lean soft-tissue mass as a more accurate method for dosing chemotherapy, as compared to body surface area. In this review, we summarize the current evidence that supports interactions between skeletal muscle and chemotherapy, the role of lean soft tissue in predicting chemotherapy toxicities and potential use of an alternate method of chemotherapeutic dosing, all based on quantification of skeletal muscle mass by computed tomography.